VanGrossMD | 66 New Health Care Reform Proclamations
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66 New Health Care Reform Proclamations

Posted by vangrossadmin in Healthcare Revolution 01 Apr 2015

By Kenneth Van Gross, MD
Miami, Florida
updated 4/15

“The 66 for the FIX”

  1. Here forth is announced a national moratorium on “business as usual” in doctors’ offices. Instead, we provide everyone a “multi-specialty check-up (MSCU)” tied together by a summary from a primary care physician (PCP).
  2. The benefits of this would be to allow members of the public to answer key questions about their health. Do they need a Stress Test? Do they need a skin biopsy? Do they need an MRI of their hip? Key term: Fresh Look
  3. Cardiovascular and Cerebrovascular disease evaluation and treatment will get a great boost from this approach. These diseases are the first and third leading killers in the US.
  4. But Cancer screening through this approach will be magnificently improved upon. Cancer of course is the second leading killer in the US.
  5. A better understanding of medical care costs would be achieved through this program.
  6. Some kind of estimate of the cost for this government sponsored screening will be tied into the Medicare Model for ongoing evaluation and treatment.
  7. It is clear we have to separate outpatient medical evaluations from everything else in the “healthcare conundrum”. That outpatient issue is the one that is the overwhelming time/cost dilemma and it is a start in better understanding the inpatient costs. It would seem to me that if we improve outpatient evaluation and treatment, we decrease inpatient activity and thus decrease its cost.
  8. It will also be very important not to “offend” others in the health care system such as chiropractors, dieticians and occupational therapists. The thrust of the MSCU is to clarify what patients need now medically (though MD’s will also submit recommendations re: things like rehab services.)
  9. Let’s assume for the sake of argument that this “Grand Plan” is rejected. I believe it still allows the Strong Public Option(SPO) Team to articulate something beyond what has been heard so far in the debate, i.e. that all the system needs is a new insurance plan.
  10. Take the Bill Clinton or Tim Russert cases where these two wealthy guys had emergency issues that need not have occurred. In Clinton’s case, he had coronary artery disease that should have been addressed years earlier. Instead he required a very expensive urgent multi-vessel bypass. Russert’s case was far worse though far cheaper: sudden death due to unrecognized heart disease.
  11. If Clinton and Russert had had an MSCU and PCP synthesis years ago, Clinton might have avoided expensive heart surgery and Russert may well have survived into 2009 and beyond (far healthier than he was on the day he died).
  12. A powerful point I have not heard in the reform debate is the nature of medical care as a professional endeavor rather than as either a business or “test and drug ordering” service.
  13. I tried to convey that in circulating a video of patients with Encephalitis. More than anything else, physician “cognitive services” lead the way into quality medical care. This takes time. It would take money to help justify such an expenditure of time but I see that as the crux of the cost issue because what you have now is the justification of physician non-reimbursed face time with patients/ thoughtful case analysis by profligate ordering of frequently worthless though remunerative medical tests.
  14. This is not to say that we should return to 1950 when the neurologist for example had nothing more than a spinal tap and a few good guesses in his armamentarium.
  15. But in the interest of medical care quality, we must mandate a decrease in costs of medical testing.  This is already done through the Medicare model but it needs universal application. The big losers in this model? No one. The technology industry may well end up doing a higher volume of certain tests while getting paid less for each one.  But you know, some medical technology industries may suffer!!! How horrid!!! These billionaires reduced to the ranks of mere millionaires. What garbage right? A businessman worth anything will simply shift his capitalist instincts and dollars to a more lucrative business, health care or otherwise.
  16. The problem is there will be limits on physician earnings. I would maintain that most physicians would take a guaranteed high income for heavy hours though they will not be able to “make a killing” running their practice like a business.
  17. Of course, heavy economic constraints are already in place for the vast majority of physicians, so we are really talking about semantics. Plus, the disincentive for using medical practice as a vehicle to mega-bucks is balanced by the great benefit that a high income will be guaranteed given a high load of work.
  18. Remuneration to physicians will also have to be structured based on specialty as some surgical specialties mandate long hours doing operations while seeing far less patients than say a non-surgeon such as a general internist.
  19. The outcry for such an idea might be deafening in some sectors of the physician community, but let’s see the poll numbers by offering to actually have a referendum among physicians on this matter.  Remember, there is great anger at the system that is in place now. Most physicians want a Strong Public Option!!
  20. So again, we may well have a situation where there’s too much resistance for any “set income” for physicians, but we are at least explaining why a Strong Public Option without such mandates amounts to the same thing because you won’t be able to “milk” a well structured universal Medicare model into the Warren Buffett money category or even offer up an unlimited buffet built on “running the table” on worthless or semi-worthless testing.
  21. Next topic: How can we actually make Health Care a money maker for the American economy?
  22. We need to produce many more home-grown physicians and allied health professionals.
  23. 50,000 Indian born doctors are here. That’s a number that needs to be studied because it’s built on a need that we have created while many Americans must forego medical careers due to an inability to find medical school slots in which to train them.
  24. Some who are shut out in this country pursue a pitfall ridden off shore education without a definite chance to get certified here.
  25. We should have a national initiative to produce more American born MD’s. We might also infuse the GNP with needed cash by sending many abroad. I know this is something done by Cuba but let’s face it: China makes shirts and trinkets.  We can provide mighty intellectual property. Instead, we will eventually get over run by Chinese doctors coming here while we can’t produce enough of our own.
  26. And why shouldn’t we help the Americas in medical problems through this better kind of army than one fighting trillion dollar wars based on flawed logic?
  27. Obviously however, the greatest value of this American Medical Corps will be to help our own by cutting wait times to see doctors and getting many more people needed specialty care.
  28. Would physician incomes go down because there are more of them? I don’t think so. There will be far more patients in the pool with the universal coverage offered by a Strong Public Option.
  29. And what are we going to do with Debbie and Sandy and Billy who currently are exclusively on the administrative side of the “doctor biz”? They’ll be offered training on the patient care side where they can really help people rather than wasting valuable time filing stupid papers over “pre-existing conditions” and such, career tasks that have helped to cripple the system.
  30. A national nurse initiative? Boy do we need one. And nothing against boatloads of Philipino nurses brought here to save Joe Hospital Owner some bucks but Americans need jobs.
  31. Essentially, what I’m suggesting is that through a Strong Public Option and associated initiatives, we open a new American War on Disease. It’s a national initiative to massively cut costs by ending the only for profit HMO sector. At the same time, it’s a program that guarantees our inalienable right to get quality evaluation and treatment. Thirdly, SPO will take the 48 million with no health insurance and the tens of millions with inadequate insurance and guarantee all will have high quality services available.  Fourthly, we become a nation dedicated to health by creating this giant health care work force spearheaded by doctors, physician assistants and nurses born and educated in this country. Money pours into the US economy as a result and we have something more to export other than grain and limestone. We will export medical and allied health care professionals!!
  32. Now what about research, the cost of pharmaceuticals and some details re: specialty care vs. primary care medicine.
  33. Research: This is another disaster in medicine. It’s too scatter shot. Millions of dollars here, millions of dollars there. Not enough goal directed activity. All kinds of special interest cottage industries going nowhere. Broad pronouncements on stem cells. Not enough focused research to identify stem cell solutions for certain diseases.
  34. We need to look at all the major and minor diseases one by one and develop rational strategies to develop new treatments for each. Yes, one needs a certain degree of free marketeering to incentivize private research but we are now at an economic impasse. The “interesting science project” mindset of the ‘80’s and ‘90’s should be laid to rest. We just can’t afford what amounts to mental masturbation in the interest of science.
  35. “Guidelines” is a dirty word for many in medicine and research who don’t want some bureaucrat dictating what they can or cannot do in their clinic or lab. However, we must have some in this new “interest of science” which is to come to grips concerning what is legitimate research for certain diseases based upon harsh analysis of what is and what is not curable or even treatable. And of course, if we don’t realize that there are cost-benefit ratios in this regard, we’re sinking the world of research into a deeper more wasteful hole.
  36. And not all breakthroughs are expensive. In the 80’s, a simple and cheap medical hypothesis that peptic ulcer disease was mostly caused by a bacteria revolutionized the field and led to billions in cost saving over these last two or three decades.
  37. So again, I suggest a Clinical Research Inventory whereby we gather data on large numbers of diseases and establish a “game plan” to move forward in a way that is oriented to reasonable goals, saves the system money in the short run and earns the US economy money in the long run.
  38. I can hear the dissenters now: “Too draconian. This is not the former Soviet Union.” Okay, I have an idea. Instead, let’s funnel billions into Alzheimer’s research to perpetuate the careers of a few chosen few who themselves are skeptical about what they are doing- “but it’s a living”. We also need some honest debate about what is controversy and consensus in the medical research arena.
  39. What we have now is “smoke and mirrors glibness”, the kind you see when Tylenol PM is advertised as if it’s got some secret and wonderful ingredient heretofore not available in helping insomnia.  What hogwash!! It’s made up of a little Tylenol plus an antihistamine that’s been around for years.
  40. This advertising charade of course drives the entire pharmaceutical industry. We need to bring it to a screeching halt not only by preventing drug companies from giving out pen lights to doctors at lunches they throw for them. We need to transfer advertising dollars generated by the misinformation propagated in commercials to meaningful research endeavors while mandating lower costs of all medicines now.
  41. Cancer chemotherapy is a multi-billion dollar industry in its own right. We need to work towards curing cancer, not to perpetuating public relations games dedicated to the development and distribution of expensive drugs that have become business ends more than anything else.
  42. And haven’t we learned our lessons from the NSAID saga? NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) are all very much alike though their prices vary greatly based on misapplied business models designed to rip off the public. And of course, so many developed vascular disease problems related to some of the more expensive versions of these pills. What a bonanza for lawyers!!
  43. Speaking of lawyers and the world of personal injury, car accidents, workers compensation and the whole diabolical troika of insurance companies-doctors-lawyers.  This industry needs to be shut down too under a Strong Public Option.
  44. Doctors will be making bucks in SPO seeing real patients. They won’t have time for cost shifting that is the world of expensive testing in the context of some trivial accident.
  45. Let’s all now shed a collective tear for the many insurance companies, certain ambulance chasers, personal injury sleazologists and doctors pimped to keep the Accident Insurance racket going who will see massive cuts in their incomes should a SPO take hold. I have an idea, let the insurance companies work to provide needed insurance to many more for genuine issues while they cut premiums on car insurance, doable because car accident injury will become less expensive under SPO.
  46. Personal injury Lawyers and their SPO induced crisis? Here’s a joyous idea for them as their pocket books shrink under SPO. They create HMO equivalents for legal services owned by fat cat managers of lawyers. Give lawyers a pittance for complex services that are rationed.
  47. Again, there would be anger for many in the legal community to hear this, but just raising the specter of “an HMO model for legal services” will show the country why instituting for-profit constraints on a profession is anathema.
  48. Instead, in a benevolent universal Medicare model equivalent, let them make all kinds of reasonably priced and remunerated legal services available in areas where few are found now because it’s currently not lucrative enough- civil right laws, employment law and services for the poor.
  49. Medical Malpractice- this is another General Motors that must be retired as a cash cow for the legal profession. SPO must include new regulations to shut down this nauseating money machine also known as the “national nail a doctor lottery”.
  50. Specialty Care vs. Primary Care: both need major upgrades; both need to be under the SPO Umbrella
  51. Why does Primary Care need the SPO Umbrella?
  52. There are a number of reasons starting with the fact that we need a mechanism to increase the number of Primary Care Physicians. Under my conceptualization, SPO would lead to high volume well remunerated primary care practices. PCP’s can’t perform effectively with all the constraints imposed on them by HMO’s at present. On the other hand, Primary Care Medicine without an SPO incentive will continue to be relegated to the “not attractive” category for graduating trainees coming out of residency programs.
  53. There is another critical reason for enhancing the PCP ranks. It’s a public health thing. With strong numbers of PCP’s and prestige to this field, there will be more opportunities to sing the praises of preventative medicine. PCP’s are really health maintenance specialists. That’s not an expensive endeavor.
  54. What we cannot allow is this trend towards rewarding PCP’s for reaching certain milestones or goals in their patients through schemes that reward good outcomes. Medicine is just too complex to allow for that. No two patients can be compared to the max because each will have a set of diseases and medication responses that distinguishes one from the other.
  55. Where do PCP’s come from? Currently, many are foreign trained because we aren’t producing enough. We need to swell the ranks of American trained PCP’s and improve the job market in so doing. It would be great for minority communities to produce their own PCP’s.
  56. There’s an academic reason for more PCP’s too. In the HMO model, PCP’s are construed as a glorified triage service, i.e. Gatekeepers. In fact, PCP’s need to make great use of Specialty referrals to optimize patient care. This can be attained through the Medicare Model of Specialty referral. There will be no limits to PCP’s in deeming a referral to a Specialist as necessary.
  57. Beyond that, patients themselves can choose to see a Specialist through the SPO “universal Medicare-style” program.
  58. As part of my US Physician Army, both PCP’s and Specialists can be dispatched to other countries to “sell our services”. As opposed to the government enslavement in such programs, we can work out a formula whereby both the dispatched physician and the USA get reimbursed for foreign service. This can expand into Americans taking leadership roles in overseas medical schools we can establish whereby governments pay the US to launch medical education programs to produce doctors in their countries. We might also do the same in establishing Medical Research Centers that are win-win situations for our economy and the countries receiving US medical scientists.
  59. Specialty Medicine is the American jewel now. What is so disheartening is that we have misused, overused and abused this broad sector to the economic detriment of our entire American economy.
  60. But the paradigm of Specialty Care has been so obfuscated. It may take a surgeon 10 months to learn to do a procedure, but 10 years to learn when not to do that procedure.
  61. The problem is that decision not to do a surgery is not reimbursed. In fact, cognitive services don’t compare to rampant “state of the art testing”.  Simply remunerating a physician to spend more time observing a patient in the throes of an impending stroke may be more effective in terms of cost and outcome than a bunch of tests that don’t contribute much more than a partial walletectomy.
  62. We need to solve that problem through an SPO reimbursement program that doesn’t punish Specialists economically for ordering fewer tests or doing fewer operations. At the same time, Specialists need fair though not exorbitant payments for their high tech studies and procedures.
  63. Again, we need more American born and American trained Specialty physicians. We need to identify ways to heavily improve those numbers. Neurology and Psychiatry are two fields where more physicians need to be brought in- SPO would be a great attractor for those fields currently under terrible constraints by HMO’s (for different reasons).
  64. Great advances in diagnosis (imaging, endoscopies, deep tissue biopsy) and treatment (stem cell, bone marrow and organ transplantation, emerging medication for rare, degenerative, infectious, inflammatory and malignant diseases) often require outstanding Specialty care. Our system underutilizes the benefits that could be offered so many more Americans under the Specialty care wing of SPO.
  65. Tight interaction between PCP and Specialist will be a natural under a free and open SPO system. Input from physician assistants, nurse practitioners, physical therapists and other allied health professionals will be a needed part of the mix but we must develop and refine the SPO system as revolving around the professional lead of physicians along with the public health and economic benefit thereby derived. This fusion of Generalist and Specialist physician resources can also be cultivated to new heights with continuing medical education programs such as my own interdisciplinary Fusion Clinical Multimedia project.
  66. A Strong Public Option has far reaching and beneficial consequences for this nation under great economic stress in this time of terrible erosion of medical care in the context of exciting medical advances. Let’s regroup and begin a very much needed revolution under the Strong Public Option banner.